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BLS training for high risk populations

Question Type:
Intervention
Full Question:
For people at high-risk of OHCA (P)  (P), does does focussed training of likely rescuers (eg family or care-givers) (I) (I), compared with no such targeting (C), change Survival with favorable neurological outcome at discharge, ROSC, bystander CPR performance, number of people trained in CPR, willingness to provide CPR (O)?
Consensus on Science:
We found 32 studies relating to CPR training in likely rescuers (eg, family or caregivers) of high-risk OHCA groups. These studies used varying methods for CPR training and assessment of outcomes. In brief, there is insufficient evidence on patient outcomes to support or refute the use of training interventions in high-risk groups.(Dracup 1986, 1757; McDaniel 1988, 2029; Eisenberg 1989, 443; Higgins 1989, 1102; McLauchlan 1992, 7; Dracup 1994, 116; Dracup 1998, 219; Dracup 2000, 3289; Sanna 2006, 685; Bardy 2008, 1793; Pierick 2012, 1140) Existing evidence on educational outcomes suggest likely rescuers are willing to be trained,(Komelasky 1990, 387; Dracup 1994, 116; Moser 1999, 326; Kliegel 2000, 147; Schneider 2004, 295; Haugk 2006, 263; Blewer 2012, 787; Knight 2013, 9) are likely to share training with others,(Pane 1989, 152; Kliegel 2000, 147; Blewer 2012, 787; Greenberg 2012, 166; Barr GC Jr 2013, 538; Knight 2013, 9) are unlikely to seek training on their own,(Dracup 1994, 116; Greenberg 2012, 166) and, after training, are competent in BLS skills and/or knowledge.(Moore 1987, 669; Dracup 1989, 61; Wright 1989, 37; Komelasky 1990, 387; Sigsbee 1990, 662; Long 1992, 30; Komelasky 1993, 96; Messmer 1993, 217; Dracup 1998, 170; Kliegel 2000, 147; Sharieff 2001, 93; Brannon 2009, 133; Khan 2010, 299; Blewer 2012, 787; Barr GC Jr 2013, 538) For the critical outcomes of survival with favorable neurologic outcome at discharge and ROSC, we have identified low-quality evidence (downgraded for risk of bias, indirectness and imprecision) from 3 RCTs(Dracup 1986, 1757; Dracup 2000, 3289; Bardy 2008, 1793) and very-low-quality evidence (downgraded for risk of bias) from 8 non-RCTs.(McDaniel 1988, 2029; Eisenberg 1989, 443; Higgins 1989, 1102; McLauchlan 1992, 7; Dracup 1994, 116; Dracup 1998, 219; Sanna 2006, 685; Pierick 2012, 1140) The heterogeneous nature of the studies prevents pooling of data. In individual studies, there were insufficient numbers of events, with significant loss to follow-up, to be confident in the direction of the survival estimates, particularly for adult cardiac patients. The 3 RCTs followed high-risk patients for subsequent OHCA events and survival as secondary outcomes, so were not adequately powered for these outcomes.(Dracup 1986, 1757; Dracup 2000, 3289; Bardy 2008, 1793) One study reported 4 out-of-hospital deaths in 65 adult cardiac patients at 6 months (2/24 in the control group and 2/41 in the CPR-trained group).(Dracup 1986, 1757) A larger study, which was subject to high loss to follow-up, documented 13 OHCA events among high-risk children within 12 months after training of parents and other caretakers; all of these children were successfully resuscitated, and all were in the trained groups, with no events reported in the control group.(Dracup 2000, 3289) The third RCT reported 71 OHCA events in the home among 7001 adult high-risk patients with training (CPR or CPR with AED); survival was 12%, with an indirect comparison made to 2% survival for OHCA events in the home from the literature.(Bardy 2008, 1793) Eight non-RCTs were of very-low-quality evidence.(McDaniel 1988, 2029; Eisenberg 1989, 443; Higgins 1989, 1102; McLauchlan 1992, 7; Dracup 1994, 116; Dracup 1998, 219; Sanna 2006, 685; Pierick 2012, 1140) The majority of these studies relied on self-reported outcomes and were subject to high loss to follow-up or small sample sizes. One study documented higher survival rates for OHCA events in centers offering CPR training for high-risk children (28/41, 46%) when compared with centers offering no training (0/24, 0%); however, it is not reported whether the parents of OHCA children in either group had any CPR training, including the CPR training offered.(Higgins 1989, 1102) Two studies trained the parents of high-risk infants.(Dracup 1998, 170; Pierick 2012, 1140) The first study reported 75% survival for 8 OHCA events,24 all with good or stable neurologic status, and the second study reported 100% for 7 OHCA events.59 Among adult cardiac patients, who were followed-up for varying durations after training, there were very few OHCA events: 1 very small study (n=33) reported no events or deaths(Sanna 2006, 685); 3 studies report single OHCA events during follow-up after training, all of whom died(McDaniel 1988, 2029; McLauchlan 1992, 7; Dracup 1994, 116); and 1 study reported 14 OHCA events and 12 deaths among 97 OHCA survivors after training (CPR or CPR with AED).(Eisenberg 1989, 443) For the important outcome of bystander CPR performance—subsequent utilization of skills, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Dracup 1986, 1757; Dracup 2000, 3289) and very-low-quality evidence (downgraded for risk of bias) from 7 non-RCTs.(McDaniel 1988, 2029; Higgins 1989, 1102; McLauchlan 1992, 7; Dracup 1994, 116; Dracup 1998, 219; Sanna 2006, 685; Pierick 2012, 1140) The heterogeneous nature of the studies prevents pooling of data. In individual studies, there were too few events, with significant loss to follow-up, to be confident in the direction of the estimates, particularly for adult cardiac patients. The 2 RCTs followed patients for OHCA events and bystander CPR.(Dracup 1986, 1757; Dracup 2000, 3289) One study found bystander CPR was not performed in any of the 4 adult OHCA cardiac-related deaths (2 in control, 2 in intervention).(Dracup 1986, 1757) The other study reported 13 OHCA events in high-risk infants, all of whom received CPR by trained parents, with no OHCAs occurring in the control group.(Dracup 2000, 3289) Seven non-RCTs followed patients for OHCA events and determined whether bystander CPR was performed.(McDaniel 1988, 2029; Higgins 1989, 1102; McLauchlan 1992, 7; Dracup 1994, 116; Dracup 1998, 219; Sanna 2006, 685; Pierick 2012, 1140) One study documented higher bystander CPR rates for OHCA events in centers offering CPR training to parents of high-risk children (28/41, 68%) compared with centers providing no training (0/24, 0%), but it is not reported whether the parents in either group were CPR trained.(Higgins 1989, 1102) Two studies documented bystander CPR rates of 100% for 13 OHCA events in high-risk infants (bystander CPR status for 1 additional event was unknown).(Dracup 1998, 219; Pierick 2012, 1140) In 2 small studies of adult cardiac patients, there were single OHCA events, and trained individuals were either not present at the time(McDaniel 1988, 2029) or physically unable to perform CPR.(McLauchlan 1992, 7) A larger study describes CPR-trained family members using CPR on 4 occasions; 3 were successful.(Dracup 1994, 116) For the important outcome of CPR skills performance and retention, we identified moderate-quality evidence (downgraded for risk of bias) from 3 RCTs(Dracup 1998, 170; Brannon 2009, 133; Blewer 2012, 787) and very-low-quality evidence (downgraded for risk of bias) from 12 non-RCTs.(Moore 1987, 669; Dracup 1989, 61; Wright 1989, 37; Komelasky 1990, 387; Sigsbee 1990, 662; Long 1992, 30; Komelasky 1993, 96; Messmer 1993, 217; Kliegel 2000, 147; Sharieff 2001, 93; Khan 2010, 299; Barr GC Jr 2013, 538) Although these studies used different methods for CPR training and assessment, they consistently report competent CPR performance and/or knowledge immediately after training,(Moore 1987, 669; Dracup 1989, 61; Wright 1989, 37; Komelasky 1990, 387; Sigsbee 1990, 662; Long 1992, 30; Komelasky 1993, 96; Messmer 1993, 217; Dracup 1998, 170; Sharieff 2001, 93; Brannon 2009, 133; Khan 2010, 299; Barr GC Jr 2013, 538) which is usually retained in the short term(Komelasky 1990, 387; Long 1992, 30; Sharieff 2001, 93; Blewer 2012, 787) but declines over longer periods of follow-up without retraining or reminders.(Komelasky 1993, 96) For the important outcome of number of people trained, we identified low-quality evidence (downgraded for risk of bias and indirectness) from 2 RCTs(Blewer 2012, 787; Greenberg 2012, 166) and very-low-quality evidence (downgraded for risk of bias) from 4 non-RCTs.(Pane 1989, 152; Kliegel 2000, 147; Barr GC Jr 2013, 538; Knight 2013, 9) The heterogeneous nature of the studies prevents pooling of data, but overall the data suggest that family members and caregivers are unlikely to seek training on their own(Dracup 1994, 116; Greenberg 2012, 166) but, when trained, are likely to share the training with others.(Kliegel 2000, 147; Blewer 2012, 787; Barr GC Jr 2013, 538; Knight 2013, 9) The 2 RCTs examined the question from different perspectives.(Blewer 2012, 787; Greenberg 2012, 166) The first study reported CPR kit sharing rates by trained family members of cardiac patients, with a mean of 2.0 (SD ±3.4) additional family members in the continuous chest compression CPR group versus a mean of 1.2 (SD ±2.2) in the conventional CPR group (P=0.03).(Blewer 2012, 787) In the second study, adult cardiac patients were more likely to follow prescribed advice by a physician to purchase a CPR training kit than to take a traditional CPR class (P=0.0004), although few followed any advice (12/77 purchased a CPR training kit, and 0/79 underwent CPR training through a traditional CPR class).(Greenberg 2012, 166) Five non-RCTs also used different methods to examine the question.(Pane 1989, 152; Dracup 1994, 116; Kliegel 2000, 147; Barr GC Jr 2013, 538; Knight 2013, 9) One study targeted 190 OHCA survivors, with 50 of 101 responding, and 20 patients and 71 family members and friends were subsequently trained.(Pane 1989, 152) In 1 study, free mass CPR training sessions were provided, and an increase in those attending training because of heart disease after a targeted recruitment campaign (5.6% to 13.2%) was documented. In 1 study,(Barr GC Jr 2013, 538) 49% shared a CPR DVD with family and/or friends, and in another,(Knight 2013, 9) 79% shared the kit with at least 2 family members/friends. One study documented that only 18% of untrained family members sought training on their own in the follow-up period of 21±6 months.(Dracup 1994, 116) For the important outcome of willingness to provide CPR, we identified moderate-quality evidence (downgraded for risk of bias) from 2 RCTs(Moser 1999, 326; Blewer 2012, 787) and very-low-quality evidence (downgraded for risk of bias) from 6 non-RCTs.(Komelasky 1990, 387; Dracup 1994, 116; Kliegel 2000, 147; Schneider 2004, 295; Haugk 2006, 263; Knight 2013, 9) The heterogeneous nature of the studies prevents pooling of data, but there was a strong signal toward willingness to provide CPR if required in all studies. Two RCTs(Moser 1999, 326; Blewer 2012, 787) were identified as moderate quality of evidence. The first RCT documented that trainees in the continuous chest compression CPR group were more likely to rate themselves as very comfortable with the idea of using CPR skills in actual events than were the conventional CPR trainees (34% versus 28%; P=0.08).(Blewer 2012, 787) The second RCT found that the majority “would absolutely” be willing to perform CPR if required.(Moser 1999, 326) Very-low-quality evidence was identified from 6 non-RCTs.(Komelasky 1990, 387; Dracup 1994, 116; Kliegel 2000, 147; Schneider 2004, 295; Haugk 2006, 263; Knight 2013, 9) In 3 of the studies,(Dracup 1994, 116; Kliegel 2000, 147; Haugk 2006, 263) the vast majority of trained individuals stated they would use CPR if needed (79%–99%), and 1 study reported that all subjects felt neutral to somewhat confident in their comfort with providing CPR.(Knight 2013, 9) One study reported that 98% of those trained stated that they “agreed” or that they “maybe” would perform first aid (including CPR) correctly at 1-year follow-up.(Haugk 2006, 263) Another study found a slight decrease in comfort level with CPR use within 6 months after training.(Knight 2013, 9)
Treatment Recommendation:
We recommend the use of BLS training interventions that focus on high-risk populations, based on the willingness to be trained and the fact that there is low harm and high potential benefit (strong recommendation, low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place higher value on the potential benefits of patients receiving CPR by a family member or caregiver, and the willingness of this group to be trained and to use skills if required. We place lesser value on associated costs and the potential that skills may not be retained without ongoing CPR training. Because cardiac arrest is life threatening, the likelihood of benefit is high relative to possible harm.
CoSTR Attachments:
EIT 649 Grade Grid.pdf    
EIT 649 Grade Table.pdf    
EIT 649 Literature Review Updated 0915.pdf    
EIT649_BiasassessmentnonRCT.pdf    
EIT649_BiasassessmentRCT.pdf    
ETI 649 Presentation FINAL.pdf    

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